PR ACTICE GUIDELINE
Directives
Table of Contents
What Is a Directive?
3
When Is an Order Required? 3
What Information Does a Directive Need to Include?
3
Who Should Be Involved in Developing a Directive?
4
What Policies Are Needed Before Directives Are
Developed and Used?
4
What Are the Responsibilities of the NP or Physician Who Writes the
Directive and the Health Professional Who Implements It?
5
VISION
Leading in regulatory excellence
MISSION
Regulating nursing in the public interest
Directives
Pub. No. 41019
ISBN 978-1-77116-019-3
Copyright © College of Nurses of Ontario, 2014.
Commercial or for-profit redistribution of this document in part or in whole is prohibited except with the written consent of CNO. This
document may be reproduced in part or in whole for personal or educational use without permission, provided that:
• Due diligence is exercised in ensuring the accuracy of the materials reproduced;
• CNO is identified as the source; and
•T
he reproduction is not represented as an official version of the materials reproduced, nor as having been made in affiliation with,
or with the endorsement of, CNO.
First Published July 1995 as When, Why and How to Use Medical Directives
Revised and Reprinted January 2000 (ISBN 0-921127-87-1)
Reprinted October 2000, June 2003, Revised for Web June 2003, Reprinted January 2004 as Medical Directives, Reprinted December 2005.
Updated May 2008 as Directives. Updated June 2009 (ISBN 1-897308-54-X). Updated November 2011 for Bill 179 changes. Updated 2014 for
Dispensing
Additional copies of this booklet may be obtained by contacting CNO’s Customer Service Centre at 416 928-0900
or toll-free in Ontario at 1 800 387-5526.
College of Nurses of Ontario
101 Davenport Rd.
Toronto, ON M5R 3P1
www.cno.org
Ce fascicule existe en français sous le titre : Les directives, n° 51019
PR ACTICE GUIDELINE
What Is a Directive?
An order is a prescription for a procedure, treatment,
drug or intervention. It can apply to an individual
client by means of a direct order or to more than
one individual by means of a directive. For the
purpose of this document, a directive refers to an
order from a physician or Nurse Practitioner (NP).
A direct order is client specific. It is an order for
a procedure, treatment, drug or intervention for
an individual client. It is written by an individual
practitioner (for example, physician, midwife,
dentist, chiropodist, NP, or Registered Nurse [RN]
initiating a controlled act) for a specific intervention
to be administered at a specific time(s). A direct
order may be written or oral (for example, by
telephone).
A directive may be implemented for a number
of clients when specific conditions are met and
when specific circumstances exist. A directive is
always written. For the purpose of this document, a
directive refers to an order from an NP or physician.
The use of the term standing order is not
supported by the College of Nurses of Ontario.
In the past, a standing order was implemented for
every client, regardless of the circumstances. The
practitioner implementing the standing order was
not expected to exercise any judgment regarding the
appropriateness of the order for the client. It is now
recognized that knowledge, skill and judgment are
critical, and that no order, regardless of how routine
it may seem, should be automatically implemented.
Standing orders should not be confused with
preprinted medical orders that are signed by the
physician prior to implementation.
When Is an Order Required?
An order is required in any of the following
instances:
when a procedure falls within one of the
controlled acts authorized to nursing, in the
absence of initiation.1 For example:
◗ administering a substance by injection
or inhalation,
erforming a procedure below the dermis, or
p
putting an instrument, hand or finger beyond a
body orifice or beyond an artificial opening into
the body,
◗ dispensing a drug;
when a procedure does not fall within any
controlled act, but is part of a medical plan
of care;
when a procedure falls within one of the
controlled acts not authorized to nursing;
when a procedure/treatment/intervention is not
included within the Regulated Health Professions
Act, 1991, but is included in another piece of
legislation. For example:
◗ X-rays under the Healing Arts Radiation
Protection Act, or
◗ ordering laboratory tests.
◗
◗
■
■
■
What Information Does
a Directive Need to Include?
There are a number of specific components required
in a directive. They are:
the name and description of the procedure(s)/
treatment(s)/intervention(s) being ordered;
specific client clinical conditions and situational
circumstances that must be met before the
procedure(s) can be implemented;
clear identification of the contraindications for
implementing the directive;
the name and signature of the NP or physician
approving, and taking responsibility for, the
directive; and
the date and signature of the administrative
authority approving the directive; for example, the
Intensive Care Unit Advisory Committee.
■
■
■
■
■
The degree to which client conditions and
situational circumstances are specified will depend
on the client population, the nature of the orders
involved and the expertise of the health care
professionals implementing the directive.
■
1
For more information about initiation, refer to the College’s Authorizing Mechanisms practice document at www.cno.org/docs..
College of Nurses of Ontario Practice Guideline: Directives
3
4
PR ACTICE GUIDELINE
Who Should Be Involved in
Developing a Directive?
A directive is an order for one procedure or a series
of procedures. Although it is by definition a medical
document, the collaborative involvement of health
care professionals affected directly or indirectly by
the directive is strongly encouraged.
development of a feedback mechanism, including
a defined communications path. This enables the
health care professional implementing a directive
to identify the NP or physician responsible for
the care of the client, and to query the order(s)
contained within the directive if clarification is
required;
clearly stated documentation requirements on the
part of the health care professional implementing
a directive; and
identification of tracking/monitoring methods to
identify when directives are being implemented
inappropriately or are resulting in unanticipated
outcomes.
■
■
The health care team needs to determine whether
a procedure can safely be ordered by means of
a directive, or whether direct assessment of the
client by the NP or physician is required before a
procedure is implemented. Procedures that require
direct assessment of the client by the NP or physician
require direct orders.
What Policies Are Needed Before
Directives Are Developed and Used?
Before a directive is adopted as a method for
providing health care, there are a number of policies
that need to be in place. It is the facility’s governing
board, in consultation with the medical authority
and relevant senior administration, that develops
these policies and ensures they are appropriately
implemented. These policies include:
identification of the types of procedure(s) that
may be ordered by means of a directive. It must
be clear which types of procedure(s) require a
direct order, and which may be implemented
when a health care professional has verified that
client conditions and circumstances are met;
determination of the involvement of the NP/
physician responsible for the care of the client,
such as when a directive may be implemented
prior to the NP/physician seeing the client;
identification of who may implement a directive,
including any specific educational requirements,
designations or competencies (for example, only
RNs in a certain department who have completed
a continuing education course, only RNs who
have completed an in-service program, all RNs, or
all RNs and Registered Practical Nurses [RPNs],
etc.);
identification of the NPs or physicians to whom a
directive applies. It needs to be clearly identified
whether a directive is meant to apply to the clients
of all NPs or physicians or only clients of selected
NPs or physicians;
■
■
■
■
College of Nurses of Ontario Practice Guideline: Directives
■
It is strongly recommended that the above policies
are in place and understood before directives are
used to deliver health care within a facility.
PR ACTICE GUIDELINE
What Are the Responsibilities of
the NP or Physician Who Writes the
Directive and the Health Professional
Who Implements It?
The NP or physician who writes an order for an
intervention (whether that order is a direct clientspecific order or is applicable to a number of clients
by means of a directive) is responsible for:
knowing the risks of performing the intervention
being ordered;
knowing the predictability of the outcomes
associated with the intervention;
knowing the degree to which safe management of
the possible outcomes requires NP or physician
involvement or intervention;
ensuring that appropriate medical resources are
available to intervene as required; and
ensuring that informed consent has
been obtained.
Directives, correctly used, can be an excellent means
to provide timely, effective and efficient client care,
using the expertise of the NP/physician who orders
the directive, and the health care practitioner who
uses discretion and judgment when implementing
it. It is important to remember that a directive,
regardless of how generic its contents, is an order for
which the NP/physician has ultimate responsibility.
■
■
■
■
■
The health care professional who implements an
intervention on the basis of a directive is responsible
for:
clarifying that informed consent has
been obtained;
assessing the client to determine whether the
specific client conditions and any situational
circumstances identified in the directive have
been met;
knowing the risks to the client of implementing the
directive;
possessing the knowledge, skill and judgment
required to implement the directive safely;
knowing the predictability of the outcomes of the
intervention;
determining whether management of the possible
outcomes is within the scope of her/his practice;
if so, whether she/he is competent to provide such
management and if not, whether the appropriate
resources are available to assist as required;2 and
knowing how to contact the NP or physician
responsible for care of the client if orders require
clarification.
■
■
■
■
■
■
■
2
Refer to the College’s Decisions About Procedures and Authority practice document at www.cno.org/docs.
College of Nurses of Ontario Practice Guideline: Directives
5
6
PR ACTICE GUIDELINE
Notes:
College of Nurses of Ontario Practice Guideline: Directives
PR ACTICE GUIDELINE
Notes:
College of Nurses of Ontario Practice Guideline: Directives
7
101 Davenport Rd.
Toronto, ON
M5R 3P1
www.cno.org
Tel.: 416 928-0900
Toll-free in Ontario: 1 800 387-5526
Fax: 416 928-6507
E-mail: [email protected]
JUNE 2014
41019
2013-122